25C-234 (3) • • Date
6 Line St. Estimate
Southampton,rvla. 01073 11/19/2013
Phone(it 13)527-4775
Fax(413)527-8469
Name/Address Job Location
Amy Perrier 177 Bridge St.
4 Birchwood Dr. Northampton, MA 01060
Huntington, MA 01050
Terms Rep
Estimate valid for 30 days Chris
Description `total
Furnish and install 1/2"fiberboard insulation over existing roof. 9,300,00
Furnish and install ,060 reinforced rubber root'system.
Furnish and install all related flashings.
Furnish and install .032 aluminum drip edge.
All exterior rooting related debris to be removed by R.C.I. Rooting.
All work to be performed according to manufacturers'specifications.
2 year R.C.I.workmanship warranty included.
All related permits will be obtained by R.C.I. Roofing.
Winter Price:$8300.00
Customer is responsible for securing interior items and any attic debris from roof'removal.
Total $9,300.00
l'IRMS OF PAYMENT
5%Deposit
Balance upon completion Customer Signature
Registration 4 126235
Construction License;V 074334
Insured by flanas&Fickert Ins.
(413)527-2700
The Commonwealth of Massachusetts
Department of Industrial',Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
mirw.mass.gov/dia
Workers' Compensation Insurance Affidavit; Builders/Contractors/Electl•icians/Plurin.bers
.pplicant Information Please PHn:t Legibly
Iame (Business/Organization/Individual):_
,dd.ress: 12,�\-e- 5�
;ity/State/Zip: \ � MCI- o�o-i 3 Phone #:
re you an employer? Check the appropriate box: Type of project (required):
1 am a employer with 2,U 4, ❑ I am a general contractor and I 6• ❑ New construction
employees (full and/or part=time).* have hired the sub-contractors
I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling I
ship and have no employees These sub contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance, 9. ❑ Building addition
[No workers' comp, insurance 5, [1 We are a corporation and its
required,] officers have exercised their
10.❑ Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11•❑ Plumbing repairs or additions
myself, [No workers' comp, c. 152, §1(4), and we have no 12, Roof repairs
insurance required.] t employees, [No workers'
_ comp, insurance required,] 13.❑ Other
iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information:
:)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit uidicating such,
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy information,
m an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
ormatlon.
urance. Comp any Name:
licy#or Self-ins, Lia #: \�J Expiration Date: I U__45_E q
Site Address: 1Z J
tack a copy of the workers' cord ensatlon policy declaration page (showing the policy number and expiration date),
ilure,to sectue coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal per>.alties of a
.e up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
up to $250,00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification,
to hereby certify under the pains and penaltles of perjury that the Information provided above is true and correct:
gztature: .�' Date 2_-4-1 4 -
tone
Official use only. Do not write lit this area, to be completed by city or town official,
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector
6. Other
Contact Person; Phone #:
SECTION 8 •CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable O
Name of License Holder: May �j
h )ie , e. 3 _
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable O
Company Name J Registration Number
HaoreS� } �1 Expiration Date
_ � 1�1� b� e�. �,l 1315
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 4z No...... 0
It. - Home Owner Exemption
The current exemption for"horneowners"was extended to include Owner-occupied Dwelfts of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided hat the owner acts
2s supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is, or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
suructures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible fbr all such work performed under the building permit.
,as acting Construction Supervisor your presence on the job site will be,required from time to time,during and upon
completion of the work-for which this permit is issued.
.also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you mly,be liable for pemson(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature.-a nblej
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition [❑ New Signs [❑] Decks [M Si [p] Other[❑)
Brief Description of Proposed
Work: mn�&
Alteration of existing bedroom Yes No Adding new bedroo Y o
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
sa. if New house and or addition to eXisti:ng housing, complete the following!:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves —Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?_
h. Type of construction
i. Is construction within 100 ft. of wetlands?_ Yes No. Is construction within 100 yr, floodplain__Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, (��Nu �).e--f C 1, �( -.` , as Owner of the subject
property ) 1 -
hereby authorize a� 1 11 •
to act on my behalf, in all matters relative to work authorized by thisIbuilding permit application.
Signature of Owner Date
I, , M,���1_ijQ, aS aUt6QY i7.(J aQG�l , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing a4lication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning —
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
.0p:en Spate Footage %
(Lot area in inus bldg&paved
4 of Parking Spaces
A. Has u Special Permit/Variance/Finding ever been issued for/on the site? `
/��
��
NO v�x DON'T KNOVY �_/ YES
)
IF YES, date iuued:| / '
IF YES: Was the permit recorded at the Registry nfDeeds?
NO ^_/� � DON'T KNOW �-»+�� YES
IF YES: enter Book Page! i and/or Document �� �
/
B. Does the site contain abrook, body of water nrwetlands? NO 0 DONTKNOV 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to beobtained »~� Obtained /~� Date Issued: !
\~/ �-/ ' ' { /
C. Do any signs exist on the property? YES ��/�� NO
IF YES, describe size, type and location: | �
D. Are there any proposed changes to or additions of signs intended for the property ? YES ���~� NO �~���
IF YES, describe size' type and location: || /
|
E. Will the construction activity disturb(clearing,g�ding ��on. orfiUing)over 1 acre orin�pa�ofo common plan
�atwill di�udbover 1oo�? YEGK� � NO ��
»��
|F YES, then e Northampton Storm Water Management Permit from the DPVViarequired.
Department use only
FEB — 7 204 iy of Northampton Status of Permit:
` B Ilding Department Curb Cut/Driveway Permit
I 12 Main Street
Lc, ections Sewer/Septic Availability
60 ROOn'1100 WaterNVellAvailability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 1
1.1 Property Address:
This section to be completed by office
I -A—I E� aq`� "��- 1. Map Lot Unit
/j C,A` XCL WN `\\�i' Zone i Overlay District_
Elm St.District _ CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
2tc t-f LI rC wce� Off. 1r�nt,�c\c , nllA bIC_5C
Name(Print)-) Curr nl Mailing Address:
_� ,taeked 1413) J�-l- 4q Z9
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address: 010113T
( q13) 521-
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
}�
completed by ermit applicant
1. Building ROA n C) C3C (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 +2+3 +_4 +5) O , C'o Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
177 BRIDGE ST BP-2014-0858
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-234 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-0858
Project# JS-2014-001504
Est. Cost: $9300.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin RCI ROOFING 74334
Lot Size(sq. ft.): 18513.00 Owner: GOLOB BERNARD M C/O AMY M PERRIER
Zoning: SC(64)/URC(36)/ Applicant: RCI ROOFING
AT. 177 BRIDGE ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:21712014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW RUBBER ROOF SYSTEM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 2/7/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner